Healthcare Provider Details

I. General information

NPI: 1346451465
Provider Name (Legal Business Name): DEACONESS MEMORIAL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W 13TH ST SUITE 321
JASPER IN
47546-1855
US

IV. Provider business mailing address

PO BOX 150
JASPER IN
47547-0150
US

V. Phone/Fax

Practice location:
  • Phone: 812-996-7918
  • Fax: 812-996-1644
Mailing address:
  • Phone: 812-996-7918
  • Fax: 812-996-1644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01038423A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200048850P
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name: KEITH MILLER
Title or Position: CAO & INDIANA REGION PRESIDENT
Credential:
Phone: 812-996-0507